Kim Lewis

In all the discussion around the changes in the Five-Star Quality Rating System, one area has been neglected: how a facilities ranking could hinder a skilled nursing facility’s ability to receive a mortgage. 

In a bill proposed by Rep. Mark Walker (R-NC) in October of 2015 called The Nursing Home Accountability Act, guidelines were set forth that would dictate that a site with two or less stars for a period of 30 months or greater would be ineligible for any future mortgage. This moves far beyond the current practice of HUD, a key lender for nursing facilities, of using the star ratings as a factor during risk assessment. Although the likelihood of this legislation passing is low, it is a clear indicator on the attention being placed on Five-Star and a predictor of legislative focus to come.  

It is common knowledge hospitals, managed care and accountable care organizations in bundled pay areas are using the star ratings to select candidates for their PAC networks. Coordinators of care moving to use Star Ratings to determine referral paths will quickly become the norm, no matter what the market, thanks to the implementation of the Comprehensive Care for Joint Replacement (CJR) model.  The mandatory bundled payment demonstration is being viewed as clear declaration from CMS with of what the future of our industry’s reimbursement will look like. Surgeons and consumers alike are turning their attention to the Five-Star system thanks to the fantastic marketing efforts of highly star-rated SNFs. These same marketing efforts are underscoring the short fall of less star-adorned facilities in their market area.  

In adding the impending risk of legislature that would result in the drying up of funding sources, it is no wonder when considering the fact that the Five-Star Quality Rating System has moved from a scorecard system primarily leveraged for marketing and consumers “in the know,” to the backbone of future viability.  

It is time for all SNFs to embrace that if they are not actively moving forward with a plan to improve their stars, they will likely be find themselves falling behind. This loss in ground will not necessarily occur due to a decrease in the quality of care but on how the SNF compares, on a percentage scale, to their peers. If a site does not improve in a linear fashion as the industry progresses, a loss of stars is likely. This loss will first be seen with staffing and quality measure ratings, followed by a decline in stars awarded for survey results.

There ARE steps a SNF can take prevent falling stars or, better yet, have positive movement upward in their star rating. If a facility is early to the process, and wanting to get the ball moving, leveraging competencies and partnerships are two straightforward steps that can be achieved with some minor adjustments to many elements the facility likely already has in place.

Concentrate on competencies

In an environment evolving to one a quality based/ value focused reimbursement, core competency development is essential. SNFs should consider developing competencies that focus on prevention and early detection for wound / skin care, fall, and urinary incontinence. Other areas of focus should include weight loss, dehydration, infection, and dementia care. 

By creating competencies to focus not only on the acquisition of knowledge, but to include clear protocols and pathways based upon evidenced based practices that result in positive outcomes the caregiver will be empowered to be an educator to the patient and their family. It is important to include pros and cons of the outlined care options to help facilitate sound decisions by the care team, including the patient and family, especially for patients with co-morbidities.


Once the greatest areas of opportunity and the highest risk areas have been identified, come up with a cross discipline approach. Therapy services can support these efforts through educational support for nursing staff as well as therapy interventions for both short stay and long stay residents. Many of the quality measures have a direct connection to specialty areas of therapy, all have components that fall into the expertise of high skilled therapy team.  

Consistent and comprehensive screening procedures with an active culture of communication with a solution oriented attitude will create a positive impact on the quality of care in the SNF.

For facilities that have the foundational elements in place and want to further evolve the strategic plan, learning to work smarter, not harder would be a solid next step. Working smarter, not harder, means becoming competent at fleshing out meaningful and useful data.

Become a data nerd

SNF leaders should take steps to learn how the star systems are scored and the site/s individual scores for each of the component areas for quality measures and staffing. Armed with a deeper understanding of how and where the numbers come from, and exactly what is looked at for each of the areas, facility leaders will be able to formulate an effective and efficient plan of attack. This will also allow the SNF to not lose energy and efforts due to confusion and misunderstanding of the real targets.

The best place to start is the CMS website. The Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide covers the information in depth. With that guide, and a bit of Google searching on the fuzzy areas, it will not take long to be ready to start diving in to “the numbers.”  

There are a few options for finding “the numbers.” The facility’s Casper Report is a nicely formatted location that will include current scoring breakdown for quality measures. For a deeper view, the CMS website has data accessible for multiple reporting periods for download.  This data is not as “user friendly” in formatting, however it is not overly complex with a little practice.

With a deeper understanding of what data is being looked at and how performance in each of the key areas are scored, the strategic planning team can dive deeper to allow big gains from small changes.

Micromanage for macro results

Once the facility’s team has a deeper understanding of how the numbers are calculated and what each of the component scores are, you will then be able to identify two key areas. One, quality measure areas that the SNF have high potential to gain points with small gains in scoring. Two, and equally important, quality measure areas that the SNF is at risk for losing points with minor changes.  

An example of these situations can be shown with percent of residents who were physically restrained.   

The scale for determining the Star Rating covers 1100 point scale with “cuts” (the level of which each number of stars are awarded) is based on the prior year’s performances.

Each QM area can result in 100 points.  

For physical restraints, the available points for scoring for the year used for the example was 100, 60, and 20 based on CMS data.

So if the facility has a single patient with a restraint will result in a loss of 40 points.  By care planning and working interdisciplinary to come up with a safe and meaningful solution for reducing the need for the physical restraint, this step would improve the scoring by 40 points.  

Conversely, a facility that is currently functioning without physical restraint would incur a 40 point loss with even a single incident of physical restraints being implemented.

Facing the brutal facts is difficult, but now is not the time for SNF leaders to bury their heads in the sand.  Not devising a systematic plan to move ahead in the Five-Star Ratings race is a must. The steps are manageable. Standing still is not an option. Each step outlined above can resulted in positive momentum and movement forward at a facility level. Coupling the steps into a strategic plan of attack will give a facility the best chance of moving ahead of the pack.  

Kim Lewis is a vice president of clinical advancement and data integration at TMC Services in Florida. The company provides therapy services in skilled nursing and assisted living, as well as auditing and consulting services.